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Säkra förbättringar Pernilla Ulfvengren Associate professor Human-technology system Head of Industrial management INDEK KTH Royal Institute of Technology,

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Presentation on theme: "Säkra förbättringar Pernilla Ulfvengren Associate professor Human-technology system Head of Industrial management INDEK KTH Royal Institute of Technology,"— Presentation transcript:

1 Säkra förbättringar Pernilla Ulfvengren Associate professor Human-technology system Head of Industrial management INDEK KTH Royal Institute of Technology, Stockholm

2 Relevant and real research need! Aviation in the world are facing great system changes du to future Single European Sky and new requirements for Safety Management Systems Aviation stakeholders are under great competition and many under great financial pressure Aviation industry, due to this, need to manage change, risk and performance in an integrated system. The goal is to develop a system that enables the service providers to let reliable and relevant indicators drive sustainable change to improve the operational process and the Air Transport System safety performance. KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

3 System of systems Operations deliver the outcome. Organisational processes supports the improvement of operations. Bildkälla: KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

4 Integration! Aviation Transport System Industry and Academia Management systems for risk, change, performance and organisational learning Strategic, tactical and operational organisational level Intra-organisational (between production areas) Inter-organisational (Airline-MRO) Safety production logics (Person and System safety) Value systems (Quality and Safety) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

5 Research in EU-projects All coordinated by Trinity College Dublin APRG, McDonald HILAS (EU-FP6) Human Integration into the Lifecycle of Aviation Systems MASCA (EU-FP7) MAnaging System Change in Aviation PROSPERO (EU-FP7) Proactive safety performance in operations Networks HALA! (SESAR) -Higher Automation Levels in Aviation KTHs Transportplattform KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

6 Human Factors Engineering for over 30 years…need for change of focus towards management! 1. HMI (human-machine interaction, individual level, interface). Technology that make us smart 2. Work (content, function allocation, automation, procedures) 3. System (strategy, management, culture) Organisations and management that make operations smart We cannot change the human condition but we can change the conditions under which people work! Reason, 1997 KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

7 Old Safety models KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

8 Compliance vs Resilience WIPIDO (HILAS, 2005) -Well Intended People in Dysfunctional Organisations Perceived or real lack of resources Strong professional culture Loyal employees, making an effort Organisations that even after incidents do not fix the problem Support operations! HRO – High Reliability Organisations -Migrating decision making, allows for adjustment Resilience -acknowledge the fact that similar acts lies behind failure and success! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

9 Completion Compensations Conditions The bridge over the ’river’ of operations (Ulfvengren, 2011) Context Conditions Competence Consequences Competence KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

10 B uilding material  Organisational support, giving the conditions under which you work.  Human operators make things work, professional skills, individual capabilities and competence.  Standard, Critical and High risk operations, the operational context in which work is performed.  Gaps in the conditions, and or, competence may have negative consequences for the context.  Perceived or real lack of support at hand in the given situation may result in compensational behaviour to get the job done!  Get the job done in a safe and efficient manner! Context Consequences Completion Compensation Competence Conditions KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

11 Normal operations Demanding operations Smart Tech Org Dumb Tech Org KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren Module in training concept in MASCA (Ulfvengren, 2011)

12 Normal operations Demanding operations Smart Tech Org Dumb Tech Org KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren Module in training concept in MASCA (Ulfvengren, 2011)

13 The Safety of Efficiency Link Between Operational Performance and Operational errors (Hansen & Zhang, 2004) Positive relationship between safety and efficiency. -High delays, off-schedule flights increase human error. -But when everything goes as planned this increase safe operations. Do NOT take this too far…this does not show that all initiative for efficiency will increase safety. Essential to make sure initiatives do not compromise safety! Too much waste reduction makes operations vulnerable to small disturbances or in crises! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

14 Sagt av astronaut: ”Ground control is the extended arm of the mission crew"

15 Human Integration into the Lifecycle of Aviation System Perhaps the world’s largest Human factors project so far with 40 partners! Trinity College Dublin, TCD SAS partner Centre of excellence: KTH, SAS KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

16 HILAS model for safe, efficient and innovative business (Ulfvengren, 2009) ! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren (Ulfvengren, 2009)

17 Tecnical and organisational tools supporting a truly integrated management system KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren Integrated management systems (Ulfvengren, 2009)

18 The early HILAS prototype for an integrated indicator model This model was adopted, translated and further developed within SAS. It is based on present industry standards and best practices and helps us to identify relevant areas with no or few indicators. It broadens the use of SPI’s beyond the operational outcome and it is communicable. KPI’s Risk management key issues Performance management key issues Change management key issues Organizational learning key issues Strategic management processes QSPI’s QSPI’ Tactical management processes SPI’s QSPI’s Operational management processes SPI’s QSPI’s KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

19 HILAS Prospective Risk Analysis (Cooke, 2009) Safety performance indicators (SPIs) and low level key performance indicators KPIs and a clear link between low level SPIs and high level SPI/KPIs. Availability of tools gathering of operational data i.e the reporting tools and data structure proposed in HILAS. Availability of tools for storing, retrieving and analysing these data with the capability of providing targeted and intelligent reports on performance allowing the identification of action and change requirements; Requirement for an operational process model (OPM) and employment of a tool for facilitating the populating of the OPM, the qualitative analysis of the processes and the prescriptive identification of needs for change. An organisational structure and climate for facilitating staff engagement at all levels of the organisation. Mutual trust and a just culture is essential for capturing low-level operational data the buy in from managers to work across department on safety issues. KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

20 Analysis of complex systems! HILAS process modelling development Systematic analysis of –Co-ordination of task –Dependencies –Resources –Outcomes –Propagated risk Today called SCOPE (MASCA, 2012) We need to understand mechanisms and functionality that influence the operational process outcomes and develop a system that supports sustainable change of these! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

21 HILAS and SMS (Ulfvengren, 2009) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

22 SAS (SMS), Swedavia (CDM), AirDolimiti, Abruzzo airport Trinity college, KTH, NLR, THALES, KITE MAnaging System Change in Aviation KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

23 Safety performance ”Effectiveness of the SMS, how well it performs and manage to improve the system”. Safety performance is change capability! Responsiveness to identified needs for change! Not just identify what needs to change but implementing actual and safe changes! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

24 Managing system change in aviation (McDonald, 2012) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

25 Value systems: Safety - Efficiency Design envelope (Rasmussen, 1997) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

26 Integrated management system MASCA case study of SAFE-LEAN Safety performance management framework -Allow SPI’s to drive actual change! Develop process and methodology for CHANGE Including operational process model and analysis. Align this with SRB (FSQB) structure and process to close the loop, full cycle for safety performance. -Integrate for a Safe-Lean SAS. Control and balance protection with production. Data analysis to develop model for integrated performance monitoring. Integrate with Lean structure and process. KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

27 MASCA is NOT competing with LEAN! But we question: -the ”completeness” of LEAN for sustainable system change in aviation (and elsewhere?) -Lean’s lack of inclusion of human factors and system safety models We offer a complementary integrative perspective, methods, development of enabling technologies and mentoring. KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

28 Between HILAS and MASCA SAS showed great change capability In-house development of requirements for Prospective Risk Analysis and integrated model of KPIs and SPIs IT-risk information production tool -VisionMonitor-A Risk information sharing structure -SAG-SRB (FSQB) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

29 Instead of data silos! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

30 Integrate production areas’ performance data analysis and change KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren VisionMonitor aviation application

31 Instead of people silos! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

32 Integrate people, SAG, SRB SAG FSQB “Local SAG’s” All SPI’s Selected SPI’s “All available sources” KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

33 Safety Performance Management Framework (Ulfvengren, 2012) PROCEDURAL PM STRUCTURAL PM MASCA/CMS/New HUMAN FACTORS model KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

34 Structural framework (Ulfvengren, 2012) Enabling technologies -Information support technologies -Statistical tools -Data management (gathering, storing, retreiving) tool -SAS’s Vision Monitor Process models -Dependencies -Process analysis, indicator identification -SCOPE model and tool Organisational structure Indicators list, logic and weights -List of indicators and measures -Definitions and logic descriptions -Weight and dependencies -SPIs, KPIs, combined SPI’s/KPIs -Indicators linked to operational process and system functionality -Data mining model -Statistical analyses models KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

35 SMS as a process- a full cycle of change (Ulfvengren, 2012) KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

36 SPI action process KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

37 Human Performance (behaviour) Organisation (rules) Context Co-ordination Task/Resources/Dependencies/Uncertainty Task order (internal) Resources: -Material -People -Information Task dependencies (external) Outcome PROCESS KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

38 SCOPE, under devlopment to analyse complex systems (McDonald et al. 2012)

39 Implementing SMS Where are you? How well is it going? How do you know that? Where did you start? Where are you going to? KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

40 To really make it all work well together! When SMS is fully implemented: What organistion does the full cycle have? What procedures are included? Who does what? Who does what when? ICAO support? Is SMS checklist sufficient? Is SMS GAP analysis sufficient? KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

41 Apply SCOPE to organisational processes assessing and evaluating change, like SMS development and implementation KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

42 Aviation is the Safest Way to Travel! World road traffic - PER DAY: 3000 fatalities! ”an American kid at a US airport today is more likely to grow up to be President than to perish in an accident on her next jet flight” (Barnett, 2008): 1 in 22 million vs. 1 in 32 million! KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

43 Challenges New Human Factors model -Change focus from accidents and human performance to production process. New Safety model -Resolve issue regarding SOP and resilience Safety IS part of the business model so we need to integrate safety with business as usual. Make sure SMS is functioning as a process delivering improvements to operations, delivering outcome. Measure safety in relation to operations as a whole Regulators and operators need to collaborate with the above issues. KTH - HILAS MASCA PROSPERO copyright - P.Ulfvengren

44 Tack ! Pernilla Ulfvengren


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